Prevalence of fatigue and cognitive impairment after traumatic brain injury

Background Following traumatic brain injury (TBI) some patients develop lingering comorbid symptoms of fatigue and cognitive impairment. The mild cognitive impairment self-reported by patients is often not detected with neurocognitive tests making it difficult to determine how common and severe these symptoms are in individuals with a history of TBI. This study was conducted to determine the relative prevalence of fatigue and cognitive impairment in individuals with a history of TBI. Methods The Fatigue and Altered Cognition Scale (FACs) digital questionnaire was used to assess self-reported fatigue and cognitive impairment. Adults aged 18–70 were digitally recruited for the online anonymous study. Eligible participants provided online consent, demographic data, information about lifetime TBI history, and completed the 20 item FACs questionnaire. Results A total of 519 qualifying participants completed the online digital study which included 204 participants with a history of TBI of varied cause and severity and 315 with no history of TBI. FACs Total Score was significantly higher in the TBI group (57.7 ± 22.2) compared to non-TBI (39.5 ± 23.9; p<0.0001) indicating more fatigue and cognitive impairment. When stratified by TBI severity, FACs score was significantly higher for all severity including mild (53.9 ± 21.9, p<0.0001), moderate (54.8 ± 24.4, p<0.0001), and severe (59.7 ± 20.9, p<0.0001) TBI. Correlation analysis indicated that more severe TBI was associated with greater symptom severity (p<0.0001, r = 0.3165). Ancillary analysis also suggested that FACs scores may be elevated in participants with prior COVID-19 infection but no history of TBI. Conclusions Adults with a history of even mild TBI report significantly greater fatigue and cognitive impairment than those with no history of TBI, and symptoms are more profound with greater TBI severity.


SUPPLEMENTAL MATERIALS
Fig. S1 Age distribution of adults (18-70 years) participating in an online study of fatigue and cognitive impairment in subjects with and without a history of traumatic brain injury.Given a total of 519 subjects and 53 years of included age, an even distribution of subjects (dotted line) would include 9.8 subjects for each inclusive year of age.Based on Chi-square goodness of fit analysis, participation was not evenly distributed.When were you diagnosed (month/year)?

Start of Block: FACs
Please indicate the degree to which each item was true for you during the past 2 weeks by marking the line below, ranging from "not at all" to "extremely".How long after your last brain injury did you start to experience any of these problems?

Not at all Extremely
o Less than 6 months o 6 months to 1 year o 1 year to 5 years o More than 5 years

Start of Block: Ohio State University TBI Identification Method Questionnaire
The following questions are about injuries to your head or neck that you may have had anytime in your life.
In your lifetime, have you ever been hospitalized or treated in an emergency room following an injury to your head or neck?Think about any childhood injuries you remember or were told about. o

Fig. S2
Fig. S2 Age distribution of Total Score for the Fatigue and Altered Cognition Scale (FACs) in an online study of adult participants (18-70

Fig. S3
Fig. S3 Individualized sensitivity and specificity plots for the receiver operating characteristics (ROC) curve comparing the Fatigue and Altered Cognition Scale (FACs) questionnaire Total Score between individuals with a history of TBI and no history of TBI.
During the past 2 weeks: Q1/20 -I felt fatigued Q2/20 -I felt alert Q3/20 -I lost track of what I was going to say Q4/20 -I was forgetful Q5/20 -I had trouble concentrating Q6/20 -I felt worn out Q7/20 -I felt sluggish Q8/20 -I felt run down Q9/20 -I had trouble focusing on things I wanted to do Q10/20 -I had the energy to do what I wanted to do Q11/20 -I was easily confused Q12/20 -I felt "spaced out" like I was in a fog Q13/20 -I had to force myself to get things done Q14/20 -I was clear-headed Q15/20 -I felt tired Q16/20 -I didn't process things as quickly or accurately as I should have Q17/20 -I had to struggle to finish what I started to do Q18/20 -I had trouble paying attention Q19/20 -It was hard for me to make up my mind and reach a decision Q20/20 -I had problems feeling energetic no matter if I slept or napped If you have experienced none of these symptoms, please skip the next question.

Survey Question Flow: Screening, Demographics, and Study Questions For the Fatigue and Altered Cognition Scale (FACs) Start of Block: Screening Questions
Skip To: End of Survey If Condition: What is your age? (please t... Is Less Than or Equal to 17. Skip To: End of Survey.Skip To: End of Survey If Condition: What is your age? (please t... Is Greater Than or Equal to 71.Skip To: End of Survey.Have you had a TBI/concussion?o Yes o No End of Block:

Screening Questions Start of Block: Demographics
Yes o NoIn your lifetime, have you ever injured your head or neck in a car accident or from crashing some other moving vehicle like a bicycle, motorcycle, or ATV?o Yes o NoIn your lifetime, have you ever injured your head or neck in a fall or from being hit by something (for example, falling from a bike or horse, rollerblading, falling on ice, being hit with a rock)?Have you ever injured your head or neck playing sports or on the playground?Were you dazed or did you have a gap in your memory from the injury?had a period of time in which you experienced multiple, repeated impacts to your head (e.g.history or abuse, contact sports, military duty)?